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 2006­2008 (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.

Anticoagulant management of pregnancy following heart valve replacement in the United Kingdom, 1986-2002.

BACKGROUND AND AIM OF THE STUDY: Patients with mechanical heart valves require anticoagulation which is associated with significant maternal mortality (1-4%) and fetal complications (31%) in pregnancy. The study aim was to identify anticoagulant protocols and outcomes for pregnant women undergoing heart valve replacement (HVR) in the United Kingdom. METHODS: Women aged between 18 and 45 years and registered with the United Kingdom Heart Valve Registry (UKHVR) each completed a questionnaire, and their obstetric notes were reviewed. The data analyzed included valve type (mechanical, bioprosthetic, homograft), valve site (mitral, aortic, tricuspid, pulmonary), anticoagulation at confirmation of pregnancy, between 6-12 weeks and from 12 weeks to term, delivery, maternal and fetal outcomes, and cause of death. The summary statistics and a descriptive review of the findings are reported. RESULTS: Of 2,532 women eligible for the study, 922 responded. Among these women, 72 became pregnant, with 60 pregnancies in the mechanical valve (MV) group and 45 in the tissue valve (TV) group. Three anticoagulation regimes were used during early pregnancy: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH) or warfarin. All women received warfarin in the second trimester and heparin for delivery. Live births were recorded in 30% of MV pregnancies and in 60% of TV pregnancies. Miscarriage rates differed markedly (37% MV versus 2% TV). Fetal outcome was poorest in the warfarin-only group, with embryopathy occurring at a dose level of 6 mg. The maternal outcomes did not differ significantly among groups. High-dose heparin during the first trimester and for delivery was effective for the majority of mechanical valves. CONCLUSION: The study results illustrate the diverse and uncertain manner in which UKHVR patients are managed during pregnancy. A national notification system would record much-needed prospective information on anticoagulation and pregnancy outcomes, thus aiding evidence-based management.

Maternal mortality in the developed world: lessons from the UK confidential enquiry.

The UK confidential maternal mortality enquiry shows that not only has maternal mortality decreased since 1952, the year of the first enquiry, but also the pattern of maternal mortality has changed markedly. Major surgical causes of death, such as post-partum haemorrhage and ruptured uterus, are no longer as important as medical causes such as heart disease. The 'Top Ten' recommendations in the current report for the years 2003-2005 emphasise the need for health care practitioners to be aware of the risks that medical conditions, both pre-existing and those arising de novo in pregnancy, impose on the expectant and newly delivered mother. Training and further education programmes should emphasise the importance of medical problems in pregnancy without omitting the knowledge and skills in basic obstetrics that have made such an impact on maternal mortality in the past.

Obstretic medicine: interdisciplinary care for pregnancy and for women wishing to conceive.

The concept of 'obstetrical medicine' was established in the late 19th century, but overshadowed during most of the 20th century by dramatic improvements in surgical, anesthetic, antimicrobial therapeutics, and obstetrical methods and practice. During the last quarter of the 20th century the causes of maternal morbidity and mortality increasingly became pre-existing hereditable and acquired medical disorders and treatable or preventable medical complications of pregnancy. The role of obstetric medicine re-emerged because of surgical, therapeutic, and medical success. New professional associations have been formed to support, through education and research, the growth in numbers of clinicians from many specialties concerned with the medical care of the pregnant patient.

Obstretic Medicine: Interdisciplinary care for pregnancy and for women wishing to conceive

El concepto de «Medicina Obstétrica¼ se originó a fines del siglo 19, pero quedó sobrepasado durante la mayor parte del siglo 20 por los avances dramáticos en la terapéutica quirúrgica, en la anestesia, en la disponibilidad de antimicrobianos, y en los métodos y la práctica de la obstetricia. Durante las últimas décadas del siglo 20 las causas de morbilidad y mortalidad maternas cambiaron progresivamente hacia patologías médicas preexistentes, hereditarias o adquiridas, y a complicaciones médicas del embarazo que son prevenibles y tratables. El rol de la medicina obstétrica emergió nuevamente debido a los éxitos quirúrgicos, terapéuticos y médicos. Se han constituido nuevas sociedades profesionales que apoyan a través de la educación y la investigación al número creciente de clínicos de distintas especialidades que se involucran en la atención médica de las embarazadas.

Mid-trimester placentation assessment in high-risk pregnancies using maternal serum screening and uterine artery Doppler.

OBJECTIVE: To determine the value of uterine artery velocimetry and mid-trimester maternal serum AFP/hCG measurements in predicting pregnancy complications in a high-risk group of pregnant patients. METHODS: Eighty-eight patients with chronic hypertension, previous preeclampsia, and thrombophilia were included. Maternal serum AFP/hCG was examined between 15-16 weeks gestation. Levels > 3 multiple of median (MoM) for hCG and > 2 MoM for AFP were considered abnormal. Color Doppler ultrasound was performed at 23-24 weeks gestation. Diastolic notching and pulsatility index (PI) above the 95th percentile were considered abnormal. RESULTS: Thirty-three patients had abnormal uterine artery waveform: 8 patients had abnormal maternal serum hCG and 5 had abnormal maternal serum AFP. Bilateral abnormal uterine artery waveform was associated with pregnancies complicated by lower gestational age at delivery (p=0.05) and birth weight (p<0.01), higher rates of preeclampsia (p=0.006), SGA (p=0.0001), preterm delivery (p=0.0001), and cesarean section rate (p<0.0001) in comparison to patients with normal uterine artery Doppler. Pregnant women with elevated hCG had higher rates of preeclampsia (p=0.006); preterm delivery (p=0.005) and SGA (P=0.03) and, lower birth weight (p=0.001). No significant differences were noted for clinical outcomes according to AFP data. Conclusions. Abnormal uterine artery waveform is superior to maternal serum hCG for identification of placental pathology leading to preterm delivery, low birth weight, and preeclampsia in high-risk pregnant patients.

Association of raised titres of antibodies to Chlamydia pneumoniae with a history of pre-eclampsia.

OBJECTIVE: To establish the prevalence of Chlamydia pneumoniae (C. pneumoniae) infection in a pregnant UK population and to investigate whether C. pneumoniae infection is more common in women with a previous history of pre-eclampsia. DESIGN: Prospective study. SETTING: Academic Hospital. POPULATION: Ninety-one pregnant women (54 parous and 37 nulliparous) at 16-22 weeks of gestation were studied. Of the parous women, 32 had a previous history of pre-eclampsia. METHODS: Peripheral blood was drawn for C. pneumoniae antibodies between 16-22 and 28-40 weeks of gestation. C. pneumoniae antibodies were measured using a solid-phase enzyme immunoassay. According to pregnancy outcome, women were categorised into normal, gestational hypertension and pre-eclampsia groups. MAIN OUTCOME MEASURES: Serum levels of IgG, IgA and IgM C. pneumoniae antibodies. RESULTS: Prevalence of seropositivity to C. pneumoniae was 77%. Parous women had significantly higher levels of IgA and IgM C. pneumoniae antibodies than nulliparous women (P < 0.04). Parous women with previous pre-eclampsia were found to have higher levels of antibodies than parous women with a normal obstetric history (P< or = 0.003). There was no difference in the antibody levels in women with different pregnancy outcomes. CONCLUSIONS: The longitudinal data do not indicate an association between C. pneumoniae infection and pre-eclampsia. However, the subgroup analysis of parous women demonstrated raised C. pneumoniae antibodies in the women with previous pre-eclampsia, and therefore suggests that there may be an association between C. pneumoniae and the disease in this group.

Preeclampsia with abnormal liver function tests is associated with cholestasis in a subgroup of cases.

OBJECTIVE: To investigate whether women with preeclampsia and abnormal liver function tests have raised serum bile acids. DESIGN: Measurement of serum bile acids in serum specimens collected at the John Radcliffe Hospital, Oxford. SETTING: Imperial College School of Medicine. SAMPLE: Stored sera from 37 women with preeclampsia and abnormal liver function tests and from 19 controls. METHODS: Enzymic total bile acid assay. MAIN OUTCOME MEASURES: Total bile acid levels. RESULTS: Women with preeclampsia and abnormal liver function tests had higher median bile acid levels than controls (5.7 vs. 3.2, p = 0.01). The reason for the raised median serum bile acid levels in the patient group is that three (8%) women with preeclampsia had markedly raised serum bile acids levels. There were no obvious clinical or biochemical features specific to these patients. CONCLUSIONS: The pathological mechanisms causing hepatic impairment in some women with preeclampsia may predispose to cholestasis. As some women with preeclampsia and abnormal liver function complain of pruritus, we recommend checking the serum bile acids in this group of women. If these acids are raised the fetal prognosis may be adversely affected.

Taurocholate induces changes in rat cardiomyocyte contraction and calcium dynamics.

Obstetric cholestasis is characterized by raised bile acids, and can be complicated by intrauterine death. We have shown that the bile acid taurocholate causes loss of synchronous beating, bradycardia and cessation of contraction in cultured rat cardiomyocytes [Williamson, Gorelik, Eaton, Lab, de Swiet and Korchev (2001) Clin. Sci. 100, 363-369]. The aim of the present study was to investigate the effect of taurocholate on cardiomyocytes further. We demonstrated a reduced rate of contraction and proportion of beating cells when rat cardiomyocytes were exposed to increasing concentrations of taurocholate (0.1-3.0 mM); more marked at higher concentrations (P<0.001). Using scanning ion-conductance microscopy, we also demonstrated reduced amplitude of contraction and calcium transients with taurocholate. Our observations indicate that taurocholate affects calcium release from the sarcoplasmic reticulum and this parallels changes in contractile function. The relationship between the contraction amplitude and calcium transient is not linear, particularly at higher concentrations of taurocholate. We observed different effects in individual cultured neonatal cells; a reversible reduction in rate and amplitude of contraction in some, and irreversible oscillatory (fibrillatory) cessation of beating in others. The effects were more marked with higher concentrations. The contraction amplitude was also reduced in adult cardiomyocytes. The changes were reversible following removal of taurocholate in adult, but not in neonatal, cardiomyocytes exposed to higher concentrations (>0.3 mM) (P<0.001). In conclusion we have demonstrated that the bile acid taurocholate can cause different types of dysrhythmia in individual cardiomyocytes. These results provide further support for the hypothesis that obstetric cholestasis may produce cardiac-related sudden intrauterine death.