Progression from severe sepsis in pregnancy to death: a UK population-based case-control analysis

Objective

To identify factors associated with progression from pregnancy‐associated severe sepsis to death in the UK.

Design

A population‐based case‐control analysis using data from the UK Obstetric Surveillance System (UKOSS) and the UK Confidential Enquiry into Maternal Death (CEMD).

Setting

All pregnancy care and death settings in UK hospitals.

Population

All non‐influenza sepsis‐related maternal deaths (January 2009 to December 2012) were included as cases (n = 43), and all women who survived severe non‐influenza sepsis in pregnancy (June 2011 to May 2012) were included as controls (n = 358).

Methods

Cases and controls were identified using the CEMD and UKOSS. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals.

Main outcome measures

Odds ratios for socio‐demographic, medical, obstetric and management factors in women who died from sepsis, compared with those who survived.

Results

Four factors were included in the final regression model. Women who died were more likely to have never received antibiotics [aOR = 22.7, 95% confidence interval (CI) 3.64–141.6], to have medical comorbidities (aOR = 2.53, 95%CI 1.23–5.23) and to be multiparous (aOR = 3.57, 95%CI 1.62–7.89). Anaemia (aOR = 13.5, 95%CI 3.17–57.6) and immunosuppression (aOR = 15.0, 95%CI 1.93–116.9) were the two most important factors driving the association between medical comorbidities and progression to death.

Conclusions

There must be continued vigilance for the risks of infection in pregnant women with medical comorbidities. Improved adherence to national guidelines, alongside prompt recognition and treatment with antibiotics, may reduce the burden from sepsis‐related maternal deaths.

Tweetable abstract

Medical comorbidities, multiparity and antibiotic delays increase the risk of death from maternal sepsis.

Factors associated with maternal death from direct pregnancy complications: a UK national case-control study

OBJECTIVE

To investigate the factors associated with maternal death from direct pregnancy complications in the UK.

DESIGN

Unmatched case-control analysis.

SETTING

All hospitals caring for pregnant women in the UK.

POPULATION

A total of 135 women who died (cases) between 2009 and 2012 from eclampsia, pulmonary embolism, severe sepsis, amniotic fluid embolism, and peripartum haemorrhage, using data from the Confidential Enquiry into Maternal Death, and another 1661 women who survived severe complications (controls) caused by these conditions (2005-2013), using data from the UK Obstetric Surveillance System.

METHODS

Multivariable regression analyses were undertaken to identify the factors that were associated with maternal deaths and to estimate the additive odds associated with the presence of one or more of these factors.

MAIN OUTCOME MEASURES

Odds ratios associated with maternal death and population-attributable fractions, with 95% confidence intervals. Incremental risk of death associated with the factors using a 'risk factors' score.

RESULTS

Six factors were independently associated with maternal death: inadequate use of antenatal care (adjusted odds ratio, aOR 15.87, 95% CI 6.73-37.41); substance misuse (aOR 10.16, 95% CI 1.81-57.04); medical comorbidities (aOR 4.82, 95% CI 3.14-7.40); previous pregnancy problems (aOR 2.21, 95% CI 1.34-3.62); hypertensive disorders of pregnancy (aOR 2.44, 95% CI 1.31-4.52); and Indian ethnicity (aOR 2.70, 95% CI 1.14-6.43). Of the increased risk associated with maternal death, 70% (95% CI 66-73%) could be attributed to these factors. Odds associated with maternal death increased by three and a half times per unit increase in the 'risk factor' score (aOR 3.59, 95% CI 2.83-4.56).

CONCLUSIONS

This study shows that medical comorbidities are importantly associated with direct (obstetric) deaths. Further studies are required to understand whether specific aspects of care could be improved to reduce maternal deaths among women with medical comorbidities in the UK.

Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVE

To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth.

DESIGN

Prospective cohort study.

SETTING

OUs and planned home births in England.

POPULATION

8180 'higher risk' women in the Birthplace cohort.

METHODS

We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures.

MAIN OUTCOME MEASURES

Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth.

RESULTS

The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births.

CONCLUSIONS

The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

Experiences of the quality of care of women with near-miss maternal morbidities in the UK

We undertook a qualitative interview study of women's and their partners’ experiences of severe pregnancy complications. Across the care pathway, women identified a number of examples of good practice that made an important difference to their recovery. There were some areas where women felt the quality of care could be improved, for example during points of transition between higher level and routine care or from hospital to the community. Longer-term support and counselling were felt to be particularly valuable, and yet not always universally available. These results emphasise the importance of integrated quality care across the whole patient pathway.

Experiences with maternal and perinatal death reviews in the UK--the MBRRACE-UK programme

Established in 1952, the programme of surveillance and Confidential Enquiries into Maternal Deaths in the UK is the longest running such programme worldwide. Although more recently instituted, surveillance and confidential enquiries into perinatal deaths are also now well established nationally. Recent changes to funding and commissioning of the Enquiries have enabled both a reinvigoration of the processes and improvements to the methodology with an increased frequency of future reporting. Close engagement with stakeholders and a regulator requirement for doctors to participate have both supported the impetus for involvement of all professionals leading to greater potential for improved quality of care for women and babies.

Maternal near-miss case reviews: the UK approach

The UK has a well-established programme of Confidential Enquiries into Maternal Deaths and a national system for research into near-miss maternal morbidities, the UK Obstetric Surveillance System. The addition of a programme of near-miss case reviews, the Confidential Enquiries into Maternal Morbidity, permits a complete examination of the incidence, risk factors, care and outcomes of the severest complications in pregnancy, and enables the lessons learnt to improve future care to be identified more quickly. This in turn allows for more rapid inclusion of recommendations into national guidance and hence the potential of better health for both women and babies.

The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVES

To evaluate the impact of maternal BMI on intrapartum interventions and adverse outcomes that may influence choice of planned birth setting in healthy women without additional risk factors.

DESIGN

Prospective cohort study.

SETTING

Stratified random sample of English obstetric units.

SAMPLE

17,230 women without medical or obstetric risk factors other than obesity.

METHODS

Multivariable log Poisson regression was used to evaluate the effect of BMI on risk of intrapartum interventions and adverse maternal and perinatal outcomes adjusted for maternal characteristics.

MAIN OUTCOME MEASURES

Maternal intervention or adverse outcomes requiring obstetric care (composite of: augmentation, instrumental delivery, intrapartum caesarean section, general anaesthesia, blood transfusion, 3rd/4th degree perineal tear); neonatal unit admission or perinatal death.

RESULTS

In otherwise healthy women, obesity was associated with an increased risk of augmentation, intrapartum caesarean section and some adverse maternal outcomes but when interventions and outcomes requiring obstetric care were considered together, the magnitude of the increased risk was modest (adjusted RR 1.12, 95% CI 1.02-1.23, for BMI > 35 kg/m(2) relative to low risk women of normal weight). Nulliparous low risk women of normal weight had higher absolute risks and were more likely to require obstetric intervention or care than otherwise healthy multiparous women with BMI > 35 kg/m(2) (maternal composite outcome: 53% versus 21%). The perinatal composite outcome exhibited a similar pattern.

CONCLUSIONS

Otherwise healthy multiparous obese women may have lower intrapartum risks than previously appreciated. BMI should be considered in conjunction with parity when assessing the potential risks associated with birth in non-obstetric unit settings.

The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study

Objective To describe the management and outcomes of placenta accreta, increta, and percreta in the UK.

Design A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS).

Setting All 221 UK hospitals with obstetrician-led maternity units.

Population All women diagnosed with placenta accreta, increta, and percreta in the UK between May 2010 and April 2011.

Methods Prospective case identification through the monthly mailing of UKOSS.

Main outcome measures Median estimated blood loss, transfusion requirements.

Results A cohort of 134 women were identified with placenta accreta, increta, or percreta: 50% (66/133) were suspected to have this condition antenatally. In women with a final diagnosis of placenta increta or percreta, antenatal diagnosis was associated with reduced levels of haemorrhage (median estimated blood loss 2750 versus 6100 ml, P = 0.008) and a reduced need for blood transfusion (59 versus 94%, P = 0.014), possibly because antenatally diagnosed women were more likely to have preventative therapies for haemorrhage (74 versus 52%, P = 0.007), and were less likely to have an attempt made to remove their placenta (59 versus 93%, P < 0.001). Making no attempt to remove any of the placenta, in an attempt to conserve the uterus or prior to hysterectomy, was associated with reduced levels of haemorrhage (median estimated blood loss 1750 versus 3700 ml, P = 0.001) and a reduced need for blood transfusion (57 versus 86%, P < 0.001).

Conclusions Women with placenta accreta, increta, or percreta who have no attempt to remove any of their placenta, with the aim of conserving their uterus, or prior to hysterectomy, have reduced levels of haemorrhage and a reduced need for blood transfusion, supporting the recommendation of this practice.

Contemporary management and outcomes for infants born with oesophageal atresia

Background

Reports on the management and outcome of rare conditions, such as oesophageal atresia, are frequently limited to case series reporting single-centre experience over many years. The aim of this study was to identify all infants born with oesophageal atresia in the UK and Ireland to describe current clinical practice and outcomes.

Methods

This was a prospective multicentre cohort study of all infants born with oesophageal atresia and/or tracheo-oesophageal fistula in 2008–2009 in the UK and Ireland to record current clinical management and early outcomes.

Results

A total of 151 infants admitted to 28 paediatric surgical units were identified. Some aspects of perioperative management were universal, including oesophageal decompression, operative technique and the use of transanastomotic tubes. However, there were a number of areas where clinical practice varied considerably, including the routine use of perioperative chest drains, postoperative contrast studies and antireflux medication, with each of these being employed in 30–50 per cent of patients. There was a trend towards routine postoperative ventilation.

Conclusion

The prospective methodology used in this study can help identify practices that all surgeons employ and also those that few surgeons use. Areas of clinical equipoise can be recognized and avenues for further research identified.