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Learning from Catastrophe

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    Learning from Catastrophe Learning from Catastrophe Presentation Transcript

    • LEARNING FROM CATASTROPHE
      • “ Why Mothers Die” – CEMD(UK) – 1997-99
      • The CEMD (Malaysia) 1995-96
      • The Impoverished Developing World(WHO)
      • MMR/100,000 in UK
      • Late 30s. 420
      • Late 50s. 41
      • Early 2000s. 11
      • MMR/100,000 Risk of Mat.Death
      • 1 in
      • World 400 75
      • Developed 21 2500
      • Developing 440 60
      • Impoverished 1000 16
      • ----------------------------
      • Singapore 9 5400
      • UK 11 4600
      • Malaysia 44 270
      • South Africa 70 85
      • India 440 55
      • Ethiopia 1800 7
    • Individual Risk of Maternal Death
      • Risk for a woman in her 6 th .
      • pregnancy of dying is 1 in 330
      • where the MMR is 50/100,000
      • Risk =MMR(50)xFertility(6)
      • =50/100,000 x 6
      • =300/100,000 = 1/333
    • Maternal Mortality in the U.K.
      • 1800s –1930s 442/100,000
      • sepsis;unskilled F/D;chloroform
      • Mid 1930s – mid 1980s 442 – 20/100,000
      • antibiotics - reduced parity
      • blood transfusion - reduced criminal
      • ergometrine abortion
      • better training - 1928 Commission on
      • (for both Drs. and Mws.) MMM
      • mid 1980s – now 11/100,000
    • Investigations into Maternal Mortality
      • 1790 – Aberdeen,Scotland – Alexander Gordon – investigated puerperal sepsis
      • 1900 – Scotland – first Enquiry into Maternal Deaths
      • 1928 – England – Dept. Commission into Maternal Mortality and Morbidity set up
      • 1952 – E&W – Confidential Enquiry into Maternal Mortality established (3yrly)
      • 1985- Scotland joined with E&W to produce a 3 yrly UK CEMM report
    • AIMS –To Establish
      • 1. The Main Cause of Death
      • 2. Whether Substandard Care present
      • 3. To reduce Maternal Mortality and
      • Morbidity ratios still further by –
      • - recommending improved care
      • - directing future research and
      • audit
      • 4. To illuminate Success where results have
      • improved.
    • Maternal Deaths
      • Direct Death – due to obstetric complications or obstetric problems in management occurring in pregnancy or within 42 days of the end of pregnancy
      • Indirect Death – resulting from pre-existing disease or disease that developed during or was aggravated by pregnancy but was not due to direct obstetric causes
      • Late Death – due to Direct or Indirect causes but occurring between 6 weeks and a year after pregnancy
      • Coincidental/Fortuitous Death – due to unrelated causes occurring in pregnancy or in the puerperium
      • The ratio used in the UK is the no. of deaths/100,000 maternities ie.mothers delivered of live or still-born babes after 24/52
      • In Malaysia – the denominator used is the number of babies born
    • Substandard Care
      • Clinical Treatment Support services
      • Staffing Admin factors
      • Physical resources Patient/relative role
      • Major –contributed significantly to the death of the mother ie. different management would reasonably have been expected to alter the outcome
      • Minor –it was a relevant contributory factor. Different Management might have made a difference, but survival was unlikely in any case
      • Incidental – although lessons can be learnt, it did not affect the eventual outcome
      • Overall major Substandard care was found in 60.4%
    • From each Death was established :
      • The main cause of death
      • Special features of note
      • Risk Factors
      • Substandard care if present
      • Case illustrations
      • Lessons to be learnt
      • Key recommendations
      • Guidelines in care
    •  
    • CEMM – UK -Direct Deaths 1952-1999 No. of Mat. Deaths
      • 1954 1957 1996 1999
      • HTD 246 188 20 15(2 nd )
      • Haem 188 121 12 7(4 th )
      • Abortion 153 141 1 3(5 th )
      • T&TE 138 147 48 35(1 st )
      • Anaes 49 31 1 3(5 th )
      • Sepsis 42 46 16 14(2 nd )
    • Maternal Mortality UK 1997-99
      • MMR
      • Direct Deaths 106 5/100,000
      • Indirect Deaths 136 6.4/100,000
      • Total 242 11.4/100,000
      • Late 107
      • Coincidental 29
      • (the term “Fortuitous” is no longer used )
    • UK Maternal Deaths 1997-99 Direct Deaths
      • Thrombo-emb(30)/C.Thrombosis(5) - 35/34%
      • Hypertensive Disorders of Pregnancy - 15/14%
      • Genital Tract Sepsis - 14/13%
      • Ectopic pregnancy - 13/12%
      • Amniotic Fluid Embolism - 8/8%
      • Haemorrhage - 7/7%
      • Acute Fatty Liver - 4/3.8%
      • Anaesthesia -3/2.8%
      • Indirect Deaths
      • Cardiac Disease -35
      • Psychiatric illness/Suicide -15
      • Revised Order and Totals - CEMM-UK- 1997-99
      • Pulmonary thrombo-embolism 44
      • Cardiac Disease 35
      • All Haemorrhage 24
      • Hypertensive Disease of Pregnancy 15
      • Psychiatric 15
      • Genital Tract Sepsis 14
      • Amniotic Fluid Embolism 8
      • ------------------------------
      • Overall Substandard Care - 60.4%
    •  
    • Confidential Enquiry into Maternal Mortality-Malaysia(1991-96)
      • Differences from the CEMM-UK format
      • The Denominator used is the no. of babies born
      • Late Deaths (6wks to 1yr) are not counted
      • The terms “Fortuitous death”and “Remedial Clinical factors” are used
      • Each Report covers 2 years and deals with each year separately
      • The term“Obstetric Embolism”applies to AFE as well as VTE
      • Only 6% of cases had an autopsy report
    • Maternal Mortality Rates - Malaysia
      • MMR/100,000
      • 1930 1300
      • 1950 540
      • 1970 139
      • 1991/92 44.0 / 47.8
      • 1993/94 45.8 / 39
      • 1995/96 46.9 / 40.0
    • Maternal Mortality –Malaysia 1995- 96
      • Direct Deaths (378)
      • Haemorrhage - PPH 104 / 22%
      • Obstetric Pulm Emb (AFE 22%) 74 / 16%
      • Hypertensive Disease 61 / 13%
      • Obstetric Trauma 19 / 4.2%
      • Abortion 16 / 3.2%
      • Puerperal Sepsis 16 / 3.2%
      • Haemorrhage - APH 14 / 3%
      • Anaesthetic 11 / 2.2%
      • Ectopic 10 / 2.2%
      • Indirect Deaths(93)
      • Medical conditions 80 / 16.9%
      • ( 48 had heart disease : of these, 19 had Rh. Heart D.
      • Direct +Indirect Deaths = MMR of43.8/100,000
      • Maternal Death by Citizenship
      • Citizen 79.5%
      • Non citizen 17%
      • Unknown 3.6%
      • MMRs by Ethnic Groups
      • Race % MMR
      • Malay 48 39.5
      • Chinese 9.5 26.6
      • Indian 6.6 43.9
      • Ethnic/Mixed 17 69.3
      • Others 16.5 60.2
      • MMRs from PPH v. Ethnic groups
      • Malay - 5.16 Indian - 4.61
      • Chinese - 3.87 Others - 129.5
    • Other Features of Interest
      • MMR/100,000
      • Age – 25-29 (21%) 25.5
      • 40-44 (13%) 136.7
      • 45-49 (4%) 277.5
      • ------------------------------
      • Parity - Prims (21%) 28
      • Multips (60%) 42
      • Grand Multips (20%) 71
      • ------------------------------
      • Place of Birth
      • State Hospital (63%) 37
      • Private Hospital(9%) 20.2
      • Home (24%) 75.7
    • Substandard Care
      • Remediable Clinical Factors - 53%
      • -inadequate/inappropriate/delayed treatment
      • -failure to inform seniors
      • -inappropriate delegation to juniors
      • Contributory non clinical factors
      • Facility/Personnel factors - 20%
      • -absence of O&G Specialist
      • -inadequate staff experience
      • -remoteness/inaccessibility
      • -Unavailable blood
      • Patient factors - 30%
      • -non compliance to advice,admission and/or treatment
    • Improvements recommended from the CEMM Malaysia
      • Improved Data Capture
      • Improved Facilities – new Alternative Birth Centres –RM 3.3million spent
      • Improved Communication –telephones/ambulances
      • Improved Equipment – US scans; FHR monitors; Haemoglobinometers
      • Improved Training – Partograms; ManagementGuidelines/Protocols;Seminars/Conferences
    • Comparing Maternal Mortalities
      • Malaysia and the UK share the same 4 main causes – though in a different order
      • Haemorrhage Obs. Pulm. Emb.
      • Heart Disease Hypertension
      • Obstetric Trauma features in the Malaysian top 5
      • Psychiatric causes have entered the UK. top 5
      • In the WHO figures from the developing World, Heart Disease and Obstetric Pulmonary Embolism are not significant – but HIV/AIDS is playing an increasing role
    •  
    • Haemorrhage (Substandard Care - 71%)
      • Constant vigilance is required : Check Hb ante natally
      • Identify the mothers at high risk for PPH. Previous PPH is the best predictor
      • Each unit must have clear written Guidelines and regular drills for the management of PPH and massive haemorrhage
      • Have adequate IV access and at least 6 units of blood
      • Senior staff- Obstetrician and Anaesthetist - should be informed early in an emergency situation – and should come in
      • Utero-tonics and bimanual compression are basic in Management
      • If surgery is required consider a Brace type suture early on before the more complex procedures, int. iliac ligation or hysterectomy.If concerned call a colleague for assistance
      • Consider UAE if appropriate and available
    • Haemorrhage
      • Senior staff should be in theatre for elective surgery where there is a high risk of haemorrhage. Beware placenta praevia and the scarred uterus.Difficult cases must not be delegated
      • Particularly in Malaysia – Midwifes to be trained in venous access
      • - Retrieval teams to be made available
      • - If distance is a problem at risk mothers to stay in pre- delivery centres or Hospital to await delivery
      • - Remember the importance of Family Planning in the over 40s and in the grand- multipara
    • Pulmonary Thromboembolism Substandard Care – 57%
      • Pulmonary embolism can occur early in pregnancy - and after Vaginal Delivery
      • Know the at-risk patients – BMI 30 ; past or family history of VTE etc.
      • Prophylaxis for all at Caesarean Section
      • Display Guidelines throughout the Unit
      • Use thrombo-prophylaxis more widely
      • All must think thrombo-embolism
      • If clinically suspected - treat first then investigate
      • Investigate properly!
    • Heart Disease in Pregnancy Substandard Care –12%
      • The joint most common cause of Maternal Death in the UK –
      • The fourth most common cause in Malaysia
      • Women may minimize or deny symptoms
      • All-important to diagnose before pregnancy or at least at Booking Clinic – can be notoriously difficult
      • Counseling and Family Planning should be emphasized
      • Women with pulm.hypertension are at great risk
      • Multidisciplinary care is required ; team-work is all important
      • Balloon or surgical valvotomy becomes indicated if Mitral Stenosis is not responding to medical treatment
    • Hypertensive Disease of Pregnancy Substandard Care - 80%
      • Watch mod. to severe PET closely
      • Watch multiple pregnancy closely
      • The pregnant patient with headache and epigastric pain – requires BP and proteinuria check as a minimum check – all health-care providers should be made aware of this
      • Beware automated BP readings alone
      • Treat hypertensive crises effectively – hydralazine; labetalol
      • MgSO4 is anticonvulsant of choice to prevent fits; Valium to abort fits
      • Run the patient “dry” : Beware fluid -overload
      • Have clear written Guide lines and regular drills for Management of severe/fulminating pre-ecl/eclampsia
    • Genital Tract Sepsis Substandard Care – 50%
      • Beware the insidious onset of low grade pyrexia
      • Careful assessment required of P.R.O.M. with fever / tachycardia
      • With P.R.O.M. keep vaginal (aseptic) assessments to the minimum
      • Use prophylactic antibiotics for CS
      • Where pyrexial - take repeated specimens including blood culture for bacteriology
    • Ectopic Pregnancy Substandard Care 65%
      • All Health-care workers - beware atypical presentations
      • Urine dipstick testing for bHCG
      • Laporoscopic surgery only if competent
      • Don’t delegate difficult cases
      • Call for senior help in good time
      • Avoid unnecessary/unsupervised late night operating – if experienced staff not available
      • Beware Cx Ectopics
    • Obstetric Trauma - CEMM Malaysia 19995/96 Remediable clinical factors in 70%
      • Prstaglandins and Oxytocics must be used only with extreme caution in the grandmultiperous mother or in the presence of a previous scar
      • Mismanagement of the 3 rd stage contributes significantly to uterine inversion. All birth attendants must know correct management
      • Uterine “massage” during labour by untrained birth attendants should be banned
      • Beware disproportion in the patient with a scarred uterus
    •  
    • Worldwide Maternal Mortality - 600,000 die annually
      • World MMR - 440-1000/100,000
      • Haemorrhage 24%
      • Sepsis 18%
      • Obstructed Labour 15%
      • Unsafe abortion 14%
      • Eclampsia 13%
      • -------------------
      • Compounded by endemic TB/Malaria
      • Pattern changing - 40% have HIV/AIDS base
    • World Maternal Mortality – AIDS
      • An estimated 33 million are living with the virus – more than 2/3rds of them in Africa
      • Pregnancy itself does not appear to exacerbate death in HIV
      • Where HIV infection is high,traditional causes of MM are also high
      • Pregnancy complications are high among HIV mothers
      • The pattern of Maternal Mortality is changing – 40% of deaths have underlying HIV/AIDS -
      • non traditional deaths are now becoming more prevalent
    • Containment of HIV
      • Commitment/Investment required to reverse HIV trend
      • HIV testing for all at Antenatal Booking clinics
      • Support, Counseling and Teaching to wives and husbands
      • Reduction of mother to child transmission rates
      • Treat and bring hope to HIV+ve mothers
    • Complications and Management
      • Post Partum Haemorrhage -Treat anaemia;plan for birth; Skilled attendant at birth;Active Management;Manual Removal of placenta
      • Post Partum Sepsis – Skilled Attendant;Clean practices; Antibiotics if infection; Prophylactic antibiotics at C.S
      • Complicated abortion – Skilled attendant; Antibiotics; Replace fluids; Empty uterus; Access to safe abortion where legal; Family planning
    • Complications and Management
      • Hypertension/Eclampsia – Detect; Refer to safest place; MgSO4 as anticonvulsant; antihypertensives.
      • Obstructed labour/#uterus – Use Partogram; Early detection of dysfunctional labour; referral to equipped hospital; safe Active Management of labour; safe Trial of Instrumental Delivery/C.S.
      • Anaemia – screening; prevention and treatment
      • Malaria – Pregnant women are more susceptible
      • - Causes 5-23% of deaths in Africa
      • - Prophylaxis in pregnancy
      • - Adequate treatment is life saving
      • Skilled Attendants
      • - Midwives and Doctors
      • -Trained TBAs
      • Essential Drugs – Oxytocic; Hydralazine; MgSO4; antibiotics; iron/folic acid; tetanus-toxoid;anti-malarials
      • IV fluids; Blood; Anaesthetic agents
    • Maternal Mortality and Poverty
      • MMR –E&W – 420/100,000
      • Liverpool Ladies charity 1936 - MMR 130/100,000
      • Rochdale Experiment MMR – 1930 - MMR- 900/100,000 1935 - MMR – 170/100,000
      • ---------------------------------
      • 1984 – USA – in a group avoiding medical care, the MMR was x90 greater than elsewhere in the USA at that time
    •  
      • Maternal Mortality is the tip of the iceberg
      • The fact that it is low is no cause for complacency
      • Maternal deaths in the main follow acute maternal morbidity
      • Severe Maternal Morbidity – the “near miss”, the “interesting case” – is also very important
      • Study into Maternal Morbidity would provide very valuable fresh , relevant , additional data which hopefully would help towards prevention as well as improving management
      • It is also important to reduce the aftermath of chronic morbidity – both physical and psychological
    • Some advantages from looking into severe obstetric morbidity
      • A wealth of new information would become available – main predictors and risk factors
      • The patient also could contribute
      • The expected number of cases for a unit could be determined and planned for
      • The survival rates would provide a very useful audit of the standard of care
      • BUT - as yet there is no clear accepted definition of severe obstetric morbidity
    • Identification and Categorisation of Near-Misses
      • ICU admission
      • The CO llaborative S tudy into Maternal MO rbidity (COSMO) - Severe Maternal Morbidity ratio (SMMR)
      • Organ System failure : Primary Obstetric cause – M ortality I ndex(MI)
      • Obstructed labour in Africa
    • Severe Obstetric Morbidity(SOM)
      • Collaborative Study of Severe Morbidity
      • ( COSMO) study 1999
      • All Haemorrhage 327
      • Severe Preclampsia 187
      • Eclampsia 12
      • HELLP 25
      • Severe Sepsis 17
      • Uterine Rupture 12
      • Others 8
      • Total 588 cases
      • ( out of 48,865 deliveries)
      • There were 5 direct Maternal Deaths in the study
    • Collaberative Study of Severe Morbidity Results
      • Out of 48,865 deliveries there were 588 cases with S evere O bstetric M orbidity (SOM) giving an incidence of SOM of – 588 /48,865 = 12.1 / 10000 deliveries
      • The 5 deaths in the study were due to sepsis(3); haemorrhage (1); HELLP(1)
      • The S evere M orbidity to M ortality R atio
      • (SMMR) was – 5/588 = 118:1
    • Severe Acute Maternal Morbidity and Mortality ( from RC Pattison Proceedings 18 th . Perinatal Care Congress, South Africa - 2000 )
      • Primary Cause Mortality Index
      • Abortion 22.6
      • Ectopic Pregnancy 11.8
      • Antepartum Haemorrhage 5.3
      • Post partum haemorrhage 7.3
      • Hypertension 20.6
      • Pregnancy related sepsis 25.9
      • Embolism 77.8
      • Anaesthetic related 26.3
      • Non-pregnancy related infections 61.8
      • Pre-existing medical disease 29.5
      • It’s time to consider the problem of severe acute Obstetric Morbidity - and to combine this with the CEMM
      • How much better to learn from the triumph of a life saved than from the catastrophe of a life lost!
    • Thank you for your interest