Colombo, Sri Lanka
EditorI fully subscribe to the widely accepted view that the latest Confidential Enquiries into Maternal Deaths in the UK1 (CEMD) is the best audit of its kind in the world today, containing marked improvements on the previous one. The title of this letter is only intended to provoke discussion and debate!
The fact that the CEMDs have helped significantly to reduce maternal mortality and morbidity is undoubted, and the recent success story regarding thromboembolism deserves congratulation. However, the fact that the authors have such power to improve practice and change outcomes brings with it a responsibility, for it is incumbent on them to determine where further improvements could be made and to act on them without delay. I believe there could have been a similar success story with regard to hypertension (the second commonest cause of death), if the previous triennial reports had been more specific. Each trimester, I have looked forward to reports of improvement in this respect, but once again the 199799 report was disappointing, especially with regard to reporting anaesthetic details and recommendations regarding magnesium therapy.
In contrast, the chapter on haemorrhage was exemplary, with relevant details including the exact stage at which junior and consultant anaesthetists became involved. The recommendation that anaesthetists be involved at an early stage in planning patient management, and that for a woman at known risk of haemorrhage, any anaesthetic should be given by a consultant, is strongly worded and unambiguous. I cannot understand why this recommendation has not been extended to other high-risk situations, especially hypertension, HELLP syndrome and sepsis.
The chapter on anaesthesia stressed that delayed or inadequate consultation with anaesthetic colleagues contributed significantly to substandard care, and deplored the fact that anaesthetists are still not considered an important part of the multidisciplinary team. The need to be aware of the vital contribution that can be made by anaesthetists when adequate warning is given, and harm that can result when it is not, was emphasized. Sadly, consultant involvement was specified only in two of the 17 cases discussed in this chapter, leaving one to surmise that the vast majority of patients were attended to by trainees alone. It would certainly have been of value to know the level of expertise of the trainees involved (e.g. third year registrar, first year trainee, locum, etc.).
The three deaths directly attributable to anaesthesia also need further comment. In the first instance, when epidural anaesthesia was complicated by a dural tap and converted to a high subarachnoid block for Caesarean section, should not a senior colleague have been called in early so that the first anaesthetist need not have left a healthy young mother to deteriorate, to attend to a dying baby? Should not a consultant have been involved in the second case where a badly planned fifth anaesthetic was given for a scheduled operation on a high-risk mother in intensive care? Although the third death was blamed on over-transfusion with colloids, could it not have been due to acid aspiration?
My strongest criticism of the chapter on hypertension is that the anaesthetic care has been omitted. Most of these patients had very high arterial pressure and died after Caesarean section. Yet the anaesthesia given and the experience of the anaesthetist involved have not been recorded. Perhaps it is not unfair to assume that most of them were done under general anaesthesia by inexperienced juniors who did not use prophylactic measures to obtund the catecholamine surges at intubation and extubation, and the other stressful manoeuvres, which would certainly have contributed to, if not directly caused, intracranial haemorrhage and pulmonary oedema, the causes of death.
The greatest disappointment was that even in this latest report, the place of magnesium has been underplayed. In several instances, various cocktails have been given and magnesium avoided or only resorted to too late. Practising in a developing country, I cannot come to terms with the fact that the simple, tried and tested magnesium therapy is withheld. The recommendations given for the management of pre-eclampsia are far behind the times, magnesium being advocated too late, only after seizures have occurred. Magnesium therapy has been standard practice in the USA, Australia and other countries for decades, and its safety and efficacy are well documented. I recall that the UK lagged far behind other countries in changing from magnesium trisilicate to sodium citrate. Are they not making the same mistake with regard to magnesium sulphate?
May I make the following suggestions?
(i) The chapter on hypertension should be reviewed case by case by a multidisciplinary special interest team including practising consultant obstetric anaesthetists.
(ii) The recommendations for pre-eclampsia should be reviewed with a view to early institution of magnesium as a first-line therapy for the prevention of complications and suppression of catecholamine surges, especially during labour and general anaesthesia.
(iii) Recommendations regarding the choice of anaesthetic technique for patients with pre-eclampsia and HELLP syndrome should also mention consultant involvement.
May I also draw attention to the fact that a few typing errors have crept in, such as 20001 for 2001!
I hope these points are taken in the spirit in which they are written, hopeful that recommendations may be given before the golden jubilee of the CEMD, so that more young women need not die due to sub-standard care.
N. Rodrigo
Colombo
Sri Lanka
References
1 Why Mothers Die. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 19971999. London: RCOG Press, 2001